HJAR Mar/Apr 2022

HEALTHCARE JOURNAL OF ARKANSAS I  MAR / APR 2022 57 Scott Stern, MD Chief Medical Officer and Medical Director of Surgical Oncology CARTI Cancer Center OVER the last 15 years, the management of head and neck cancers has changed rather dramatically. The advent of better and more specific surgical procedures, the improve- ment in both types and treatment algorithms for radiation, and targeted chemotherapy have played an essential role in the ongoing battle to cure these cancers with limited side effects. However, while the addition of TORS (transoral robotic surgery) to the surgical armamentarium has been important, and certainly the advent of targeted immuno- therapy has made a significant difference, probably the single greatest factor that has changed cure rates for head and neck can- cers more than any other single treatment modality is the rapid increase in the preva- lence of HPV positive cancers. Previously, most head and neck squa- mous cell carcinomas were caused by a synergistic effect of smoking with alcohol usage as a presumed promoter of malignan- cy. However, in the last 25 years, the role of HPV (human papillomavirus) induced oro- pharyngeal cancers has played an increas- ingly more significant part in the patients we see. There are multiple subtypes of the human papillomavirus; in general, types 6, 11, 16, and 18 appear to be causative for hu- man cancers. In addition to head and neck cancer, anal and cervical cancers are also caused by these subtypes of HPV. Interestingly, these cancers have a much better prognosis. As a result, most of the research on HPV-related head and neck cancers has focused on de-escalation of treatment. The idea here, of course, is that less chemotherapy or radiation, paired with precise surgical resection, could maintain excellent cure rates with significant mitiga- tion of long-term side effects. The introduction of technology allow- ing us to test for intact HPV DNA has been pioneered by the Naveris corporation uti- lizing their proprietary test, NavDX, in the management and treatment planning for HPV-related cancers. NavDx is a blood test that allows for quantifying HPV DNA in the bloodstream. This tumor marker provides predictive information for both the patient and doctor and can be used very effectively in treatment and follow-up. The test is quite simple. Ten milliliters whole blood is obtained and sent to a cen- tral laboratory. The results are sent to the physician and the practice directly and usu- ally are available within two weeks. The re- sults quantify the amount and subtype of HPV in the patient studied. These results have been used quite effectively in patient management. For example, a patient with HPV-positive tonsil cancer underwent surgery, which in- cluded a wide field tonsillectomy and modi- fied neck dissection. The tonsil was com- pletely removed with negative margins; two positive lymph nodes were found. The NavDx returned zero after surgery, a PET scan was also negative, and no fur- ther treatment was planned. Three months later, the NavDX had increased at routine surveillance, although the patient had no symptoms or physical findings. A CT scan was obtained, which was negative. The pa- tient returned in six weeks, at which time the HPV DNA titer had climbed. APET scan demonstrated a small retropharyngeal node that was positive. Adjuvant therapy was ini- tiated well before the symptomatic disease became apparent. In a second case, a patient with bulky neck disease underwent concurrent chemoradia- tion for his base of tongue squamous cell carcinoma. He tolerated treatment well, but his physical exam was difficult because of treatment-related tissue changes, and his PET scan was equivocal. The NavDx HPV DNA titer was zero, giving both the patient and physician muchmore confidence in the treatment plan moving forward. Cancer treatment has changed dramati- cally in the last few years. Improvements in surgical technique, radiation delivery and dosimetry, and targeted immunotherapy play an essential role today for patients with head and neck cancers. The addition of highly specific and sensitive tumor mark- ers also aids in the decision-making process for treatment and allows for early interven- tion in pre-symptomatic patients. In addi- tion, being able to reassure the patient after treatment that their cancer is in remission is an important tool for surveillance and quality of life. n CARTI’s chief medical officer and medical director of surgical oncology,Scott Stern,MD, leads CARTI’s medical team in providing the highest level of care to patients across Arkansas. Stern completed a fel- lowship in head and neck surgical oncology at MD Anderson Cancer Center at the University of Texas in Houston. He attended the University of Arkansas for Medical Sciences in Little Rock, where he com- pleted residencies in general surgery and otolaryn- gology — head and neck surgery — and attended medical school.